Psychiatry Clerkship Curriculum

Psychiatry Clerkship Curriculum

 

“Natural forces within us are the true healers of disease.”
― Hippocrates

 

Attention preceptors: In order to access the uploaded articles linked below in the required reading  section, you must be logged into portal (link here). Please email at travis.smith@lecom.edu for your username and password.

 

Download this in a PDF for easier viewing (Psychiatry Curriculum 2017)

 

1   Table of contents

  1. Table of Contents
  2. Description
  3. Requirements
  4. Materials
  5. Evaluation
  6. Goals and Objectives
    • Medical Knowledge
      1. Common Psychiatric Conditions
    • Patient Care
    • Interpersonal and Communication Skills
    • Practice-Based Learning and Improvement
    • Systems-Based Practice
    • Professionalism
    • Osteopathic Philosophy and Osteopathic Manipulative Medicine
    • Psychiatry Evaluation Outline
  1. Required Reading
  2. Supplemental Learning Resources
  3. Psychiatry Journals
  4. Shelf and Board Review

 

2   Description

Psychiatry (Third Year Rotation): 1 block rotation (4 weeks:  During your 4 week rotation you are expected to meet and exceed the following requirements and challenge yourself, to be proactive learners and ask questions. This clinical experience will provide third year students with a solid foundation in the fundamentals of the evaluation, diagnosis, treatment, and appropriate referral of patients with mental health disorders.

During your rotation students will be exposed to all major psychiatric diagnostic categories including: affective disorders, anxiety disorders, psychotic disorders, alcohol and substance abuse disorders, geriatrics disorders, children and adolescent disorders, somatization disorders, oppositional defiant disorder, autism, pervasive developmental disorder, and personality disorders. Most students will be in the outpatient setting, and provided opportunities to both observe and to participate directly in patient care under the supervision of the clerkship faculty psychiatrist. Some students may follow hospitalized psychiatric patients which will allow them to gain an appreciation for the full range of psychiatric illnesses and the variety of treatment options that are available to those patients with severe illness.

The core psychiatry curriculum will be delivered through an Internet-based, self-study format. A schedule of required readings that address essential content will be provided. Remember that there is more than studying for “BOARDS.” Just because the topics covered either in the readings or online questions might not be considered “BOARD” relevant, does not mean you should not know it or be expected to know it. The boards likely will not expect you to memorize all the components of a mini mental status exam but you will be expected to know it while on your rotation. If there is a problem with one of the article links or questions, please email me directly, travis.smith@lecom.edu.

This curriculum should be used as a supplemental resource while on your clinical clerkships. It should not be used as the only educational resource for your boards and shelf exams. There is some purposeful educational overlap with the COMAT NBOME Psychiatry Objectives which can be found in full by clicking here. The merging of this information should help with your shelf exam preparation and COMLEX step II exams.

 

3   Requirements

  • Complete all reading requirements while on your rotation including text book and online readings.
    • Students are encouraged to supplement required readings with additional readings based on your specific rotation exposures.
    • 10 hours per week of outside clinical reading.
  • Complete the Weekly Online Questions of the Day in the coursework section
  • Complete the online End of Rotation Quiz (Worth 20% of your final grade)
  • Students MUST adhere to the ACGME rules regarding the workweek, which include working no more than 80 hours per week, no more than 24 hours continuously, except an additional 6 hours may be added to the 24 to perform wrap-up duties, and have at least one of every 7 days completely off from educational activities.
  • Extended absences from the clerkship are not permitted. Any absence from the clerkship must be pre-approved by the regional campus dean prior to the beginning of the clerkship.

 

4   Materials: Required and Supplemental

Required Reading Materials

  • American Osteopathic Association. (2011). Foundations for Osteopathic Medicine. Philadelphia: Chila, Anthony G. Lippincott Williams and Wilkins.
  • DiGiovanna, Eileen L.; Schiowitz, Stanley; Dowling, Dennis J. (Eds.). (2005). An Osteopathic Approach to Diagnosis and Treatment (3rd ed.). Philadelphia: Lippincott Williams & Wilkins.
  • Savarese, Robert G.; Capobianco, John D.; Cox, James J. Jr. (2003). OMT Review; A Comprehensive Review in Osteopathic Medicine. S.I: Savarese

Supplemental Reading

DSM-V-TR criteria; information about various disorders:

 

5   Evaluation: (Effective June 2017)

  • 50% based on rotation evaluation
  • 30% based on the shelf examination
  • 20% based on completion of the end of rotation quiz (50 questions) and completion of the weekly quizzes (the weekly quiz grades will not factor into your end of rotation quiz grade).
    • The end of rotation exam is due on the last Sunday of your rotation by 10PM eastern and will not be accepted late!
      • If you fail to complete the exam or fail turn it in on time (even 1 minute late), you are still required to take the make-up exam (while still receiving a 0% towards your grade)
      • If you then fail the makeup exam (<70%) or fail to take it completely by the end of your next rotation then you will be required to repeat the entire rotation during your elective month.

 

6   Goals and Objectives

  • Be able to use the biopsychosocial model of illness in the care of all medically ill patients.
  • Become competent in basic psychiatric skills of interviewing and psychiatric differential diagnosis
  • Can identify and initiate, appropriate medical/psychiatric interventions for the major psychiatric illnesses as they present in primary medical care setting.
  • To develop basic psychiatric skills and a fund of knowledge that provides the tools necessary to detect and manage common mental disorders.
  • Develop broad areas of skills include interviewing techniques, including history-taking and mental status examination of psychiatric symptoms and signs
  • Development of psychiatric differential diagnoses and a biopsychosocial formulation of patients’ psychiatric illness
  • Formulation of psychiatric treatment options, including pharmacotherapy and psychotherapy.
  • The fund of knowledge includes the epidemiology, phenomenology, pathophysiology, treatment, and course of psychiatric disorders.
  • To conduct an adequate psychiatric interview, including skills in recognizing and categorizing psychological and behavioral phenomena as described in the psychiatric mental status examination
  • Engages a patient and establishes rapport.
  • Introduces and discusses sensitive material
  • Students are expected to demonstrate care that is compassionate and effective in promoting mental and physical health.
  • Manages behavioral or emotional difficulties commonly encountered in the psychiatric interview
  • Performs a psychiatric diagnostic workup, to include: Acquiring and organizing the psychiatric history, Performing the mental status and physical exam,  Making decisions regarding further diagnostic studies
  • Diagnoses a patient based on clinical history and other information by the methodology of the multi-axial format of DSM-V-TR
  • Develops and helps execute an initial treatment plan for an in-patient
  • Students should have an understanding of psychiatric emergency screening and evaluation* (including suicide and violence assessment)
  • Students should have an awareness of psychotherapy (including basic types, indications, case formulation, developmental issues, and indications)
  • Students should have an understanding of uses of other evidence- based biological treatments (ECT, Vagal Nerve Stimulation)
  • Students should have an awareness of issues related to psychiatric practice (patient referral, levels of care, managed care, stigma, and forensic issues)
  • Students should be familiar with the knowledge and clinical problem-solving objectives as related to the Fundamental Osteopathic Medical Competency Domains, including osteopathic principles and practice and OMT, osteopathic medical knowledge, interpersonal and communication skills, practice-based learning and improvement, systems-based practice, professionalism and patient care.


6.1    Medical Knowledge

Demonstrate knowledge about established and evolving biomedical, clinical, and cognate (e.g. epidemiological and social-behavioral) sciences and the application of this knowledge to patient care.

  • Apply basic relevant genetic, epidemiology, etiology, pathophysiology, anatomy, psychopharmacology and developmental stages to psychiatric cases
  • Differentiate normal from abnormal emotional and cognitive development through the life cycle
  • Describe the pathophysiological and the natural causes of mood disorders, anxiety disorders, psychotic disorders, personality disorders, substance abuse disorders, dementia and delirium, eating disorders, childhood-adolescent disorders, and geriatric disorders
  • Apply Diagnostic and Statistical Manual nomenclature to psychiatric disorders
  • Distinguish between medical illnesses that present with psychiatric symptoms, and psychiatric disorders that present with medical signs and symptoms
  • Explain the interaction of medical disorders with psychiatric disorders
  • Identify 1st and 2nd line psychopharmacological treatment options for the major psychiatric diagnoses
  • Explain psycho-social treatment options and referral process for psychiatric disorders

 

6.1.1    Common Psychiatric Conditions

  • ADHD/Learning Disability
  • Adjustment Disorder
  • Amnestic and related disorders
  • Autism/Pervasive Developmental
    • Primary Care for Children with Autism
    • Autism spectrum disorders: an overview on diagnosis and treatment
  • Bipolar Disorders
    • Bipolar affective syndromes including signs, symptoms, epidemiology and diagnostic criteria as well as therapies for bipolar affective syndromes. Mood Disorder Questionnaire
  • Eating Disorders:
    • Treating Eating Disorders in Primary Care
    • In the Clinic: Eating Disorders
  • Defense Mechanisms:
    • The Essential Guide to Defense Mechanisms
  • Delirium
  • Dementia
    • Evaluation of Suspected Dementia
    • Frontotemporal Dementia: A Review for Primary Care Physicians
    • Dementia With Lewy Bodies: An Emerging Disease
    • Guidelines for Managing Alzheimer’s Disease: Part I. Assessment
  • Dysthymic Disorder
  • Generalized Anxiety Disorder
    • Presentation, symptoms and course of the anxiety disorders, panic disorder and agoraphobia
    • Therapeutic options for anxiety and panic disorders including drug and non-drug therapies
  • Major Depressive Disorder
    • Symptoms, signs, epidemiology and diagnostic criteria for depression syndromes
    • Treatment alternatives for depression, including therapy, antidepressant medications (including major classes and their indications and contraindications), electroconvulsive therapy and alternative and complimentary therapy.
  • Mood Disorders
  • Obsessive Compulsive Disorder
  • Panic Disorder
  • Personality Disorders
  • Post-Traumatic Stress Disorder
  • Psychiatric illness due to a general medical condition
  • Schizophrenia
    • Signs, symptoms, epidemiology and diagnostic criteria for the schizophrenias, including prominent theories of etiology as well as treatment options
  • Substance use disorders and Mental disorders due to general medical conditions/substances
    • Intoxication & Withdrawal
  • Somatoform/ Somatization disorders

Students should be able to state the indications, mechanism of action, and major side effects of the following somatic treatments:

  • Antipsychotics (both typical agents and atypical agents)
    • Adverse Effects of Antipsychotic Medications
  • Antidepressants (selective serotonin reuptake inhibitors, tricyclic antidepressants, and monoamine oxidase inhibitors)
  • Benzodiazepines
  • Mood stabilizers (Lithium, valproate, carbamazepine)
  • Medications for Substance Abuse (Antabuse, Clonidine, Methadone)
  • Electroconvulsive Therapy
  • For the shelf exam, know how patients present when they have overdosed on common street/recreational drugs (PCP, alcohol, cocaine, heroin, marijuana, etc.).
  • Health Promotion/Disease Prevention/Health Care Delivery: assessment of dangerousness, genetic counseling, cross-cultural issues, physician-patient relationship, health care financing and cost effectiveness, and medical ethics
  • History and Physical Examination: assessment methods (laboratory, neuroimaging, neurophysiologic, and psychological testing), interviewing, rating scales, assessment of physical findings and historical information, mental status examination, structural examination and DSM diagnosis
  • Management: evidence-based decision making, psychosocial interventions, clinical psychopharmacology and related somatic treatments such as electroconvulsive therapy, treatment complications, osteopathic manipulative treatment and treatment guidelines/best practices
  • Scientific Understanding of Health and Disease Mechanisms: mental health epidemiology, psychosocial foundations, neurobiological foundations, epigenetics, viscerosomatic relationships and other osteopathic principles

 

6.2    Patient Care

Provide patient care that is compassionate, appropriate, and effective for the treatment of health problems and the promotion of health.

  • Submit reports and summaries that do not reflect sexual, racial, age or cultural bias
  • Formulate differential diagnoses
  • Use a bio-psycho-social model to participate in the development of treatment plans
  • Adjust interventions that affect levels of acuity based on accommodating new information pertaining to given patients
  • Identify high risk patients who are dangerous to self and others
  • Make appropriate safety and legal decisions for patients determined to be high risk

 

6.3    Interpersonal and Communication Skills

Demonstrate interpersonal and communication skills that result in effective information exchange and teaming with patients, their patients families, and professional associates.

  • Demonstrate effective listening and communication skills by successfully restating patients comments in comparable language that accurately reflects the patient’s intentions
  • Effectively appraise the psychiatric conditions of given patients regardless of age, sex, ethnicity or race
  • Provide empathic responses to patient’s social stigma pertaining to mental illness
  • Protect patients right to confidentiality, as prescribed by ethics and legislation
  • Provide a judgment free environment in which patients feel comfortable to disclose their bio-psycho-social problems
  • Identify support networks and exchange appropriate information following prescribed procedures, with family members, and professional associates
  • Emphasize the role of the patient on the treatment team

 

6.4    Practice-Based Learning and Improvement

Investigate and evaluate their patient care practices, appraise and assimilate scientific evidence, and improve their patient care practices.

  • Identify the major sources of psychiatric information
  • Disseminate the latest trends in psychiatry during meetings, in supervision with preceptors, during grand rounds and other audiences
  • Identify and utilize resources related to evidence-based guidelines and routine psychiatric care including: prescriptive treatment methodologies frequency and content of appointments, compliance issues to medications, contracting for safety, assessment of acuity with corresponding effective decision making
  • Discern irregularities of psychiatric care in comparison to evidence-based guidelines

 

6.5    Systems-Based Practice

Demonstrate an awareness of and responsiveness to the larger context and system of health care and the ability to effectively call on system resources to provide care that is of optimal value.

  • Utilize the special expertise of psychiatrists, psychologists and social workers with respect to indications for referral and coordination of care with primary care physicians
  • Explain the overall mental health delivery system in the community
  • Explain the overall social service delivery system in the community
  • Explain how the mental health delivery system, and the social service delivery system interface with psychiatric care
  • Be conversant with the health care financing issues affecting the delivery of mental health services

 

6.6    Professionalism

Demonstrate a commitment to carrying out professional responsibilities, adherence to ethical principles, and sensitivity to a diverse patient population. Professionalism should imbue all aspects of your performance. Medicine as a whole will continue to evolve and change but this aspect of your character will stick with you forever. Each student should understand and be able to demonstrate these professional objectives:

    • Adhere to the AOA and/or AMA ethics and parameters of confidentiality
    • Combine scientific curiosity with respect for the patient regardless of age, sex, ethnicity or race
    • Demonstrate an empathic relationship with patients while obtaining information needed to participate in the development and utilization of treatment plans
    • Treat all patients, staff, and colleagues with respect.
    • Displaying good manners
    • A commitment to caring for all patients regardless of their medical diagnoses or social factors.
    • Displaying sensitivity to cultural differences
    • Avoiding confrontations
    • Demonstrate a positive attitude towards learning by showing intellectual curiosity, initiative, honesty, integrity, and dedication.
    • Showing discernment while avoiding deception when communicating with patients and their families
    • Effectively communicates empathy
    • Puts patients’ needs above own (altruism)
    • Showing intellectual curiosity
    • Accepting responsibility for your patients
    • Being prepared and on-time
    • Being dependable
    • Reliable attendance and participation
    • Strive for excellence
    • Not passing others’ work off as your own
    • Actively seek to broaden education and experience beyond clerkship requirements
    • Avoid complaining
    • Give feedback (including filling out course and teaching evaluations in a timely manner)
    • Convey humility

 

6.7    Osteopathic Philosophy and Osteopathic Manipulative Medicine in Psychiatry

Integrate Osteopathic Concepts and OMT into the medical care provided to patients as appropriate. Understand and integrate Osteopathic Principles and Philosophy into all clinical and patient care activities.

  • Be cognizant of a holistic approach to mental health problems
  • Assess for, and administer adjuvant osteopathic manipulative techniques to aid in the lessening of suffering caused by concomitant medical illnesses that may be impacting, or are impacted by, mental health issues
  • Be able to recognize and treat patients who present with Chronic Pain and Depression
    • The following objectives are taken from the following required reading topic:
  • American Osteopathic Association, and Anthony Chila. Chapter 56: Adult with Chronic Pain and Depression. Foundations of Osteopathic Medicine, 3rd ed. Baltimore, MD: Lippincott Williams & Wilkins, 2011, 903-909.

Each student must be familiar with the following OMM learning objectives:

  • How to effectively evaluate, diagnose, demonstrate a constructive clinical approach, and apply OMT in the treatment of the adult patient with the chronic pain and depression.
  • Be familiar with how chronic pain and depression are physiologically and psychologically linked in a sometimes vicious interdependent cycle.
  • Be familiar with the several perspectives within which to view this chronic pain-depression cycle.
  • List the 4 specific perpetuating factors that predict depression secondary to pain.
  • Be familiar with the osteopathic algorithm for management of patients with chronic or recurrent pain despite traditional workup and treatment.
  • Apply the five pathophysiologic models for musculoskeletal medicine for the adult patient with chronic pain and depression:
    • Biomechanical model
    • Respiratory-circulatory model
    • Neurological model
    • Metabolic-energy model
    • Behavior model
  • Be familiar with the six somatic dysfunctions commonly found in chronic back pain patients.
  • Understand the approach and emphasis that treating patients who have persistent nonmalignant pain should be on improving function, decreasing peripheral nociception and central facilitation, and empowering individuals to move forward in resuming their normal activities of daily living.
  • Be familiar with the neuroendocrine/immune connection and how the hypothalamic-pituitary adrenal axis is affected by the chronic pain state.
  • Understand why OMT is applied primarily to remove somatic dysfunction and their objective manifestations of tenderness, asymmetry, ROM alteration, and tissue texture change.

 

6.8    Psychiatric Evaluation Outline

  • Chief complaint/Identification
    • Chief complaint and why seeking treatment now
    • Describe nature, duration, severity of symptoms
    • New or returning symptoms? Past treatment if applicable –did it help?
  • History of Present Illness (include psychiatric ROS)
  • Past Psychiatric History
  • Family Psychiatric History
  • Past Medical History
  • Allergies/Medications
  • Social History
    • Family of origin/childhood
    • Relationships (marital status; lives with; children; sexuality; etc.)
    • Education –highest level attained; “how did you do in school?” “Did you graduate?” why or who not?
    • Employment
    • Legal history (DUI? Drug charges? Domestic violence? Child custody?)
    • Military history; type of discharge
    • Current life experience; what brings meaning?
    • Is the patient’s presentation due to substance use?
  • Mental Status Exam
    • Appearance and Behavior / Motor
      • General description
      • Motor
      • Expressive mannerisms/compulsions
      • Attitude/relatedness to examiner
    • Sensorium
      • Level of consciousness
      • Orientation –person, place, time and situation
      • Memory -Immediate / Recent/ Remote
      • Attention and concentration
    • Mood and Affect (range, appropriateness)
    • Thought Process
      • Production of thought (normal/thought blocking/paucity/etc.)
      • Continuity of thought (linear/tangential/circumstantial/disorganized)
    • Thought Content
      • Reality testing/delusions/overvalued ideas/self-referential thinking/etc.
      • Perceptual Disturbances (AVH)
      • Topics and issues/preoccupations/observed obsessive thoughts
      • Safety issues: SI, HI
        • Is this patient at risk of harming self or others?
        • Does the patient have a plan? Access? Intent? History of suicide attempt?
        • Does the patient require inpatient level of care? Why or why not?
      • General intellect /cognitive functioning
      • Insight and judgment
      • Diagnostic Formulation
        • Multiaxial formulation (include differential diagnoses)
        • “In order of likelihood, list no more than 5 differential diagnoses for this patient’s current problems.
        • Immediate plans for no more than 5 diagnostic studies
        • What do you want to do now?
        • What else do you want to know and how will you find out?
        • Does the patient need to be admitted?
        • If you start medications, what labs or other precautions are needed?
        • Why this medication rather than that medication
      • Therapeutic Formulation
      • Prognosis

 

7   Required Reading

Weekly Topics: Below is a suggested guide for topic review during your 4 week rotation. Attached are articles from Kaplan & Sadock’s Synopsis of Psychiatry. The articles are meant for your use only (LECOM students) and distribution or copying of these articles is prohibited.

7.1    Week 1

 

7.2    Week 2

 

7.3    Week 3

 

7.4    Week 4

 

8   Supplemental Reading Articles and Topics

In addition to the aforementioned objectives, below are some examples of supplementary resources used by the NBOME to inform the development of the Psychiatry examination as well as some supplemental reading articles on various topics:

 

9   Psychiatry Journals

In order to access these full text journals you must be signed in to my LECOM portals

 

10   Shelf and Board Exam Review

This exam focuses on diagnosis of mental illness and less on treatment. Do USMLE world questions throughout the rotation. Know the DSM criteria for diagnosis of mood disorders, personality disorders, etc. Watch out for mental illness caused by a general medical condition. Know all of the psych drugs, overdoses and side effects. Below is a breakdown of the topics on the NBOME exam. The examination consists of 125 items that must be completed within 2 hours and 30 minutes.

Patient Presentation

Adjustment Disorders 7-12%
Anxiety Disorders/Trauma Related Disorders/Obsessive Compulsive Related 11-17%
Mood Disorders 11-17%
Neurocognitive Disorders 11-17%
Neurodevelopmental Disorders 9-15%
Personality Disorders 4-8%
Psychiatric Illness Due to a General Medical Condition 4-9%
Schizophrenia Spectrum and other Disorders 4-8%
Somatic Symptom Related Disorders 4-8%
Substance Related and Addictive Disorders/Eating Disorders/Sexual Disorders 9-15%

Physician Tasks

Health Promotion/Disease Prevention/Health Care Delivery 5-20%
History & Physical 25-45%
Management 25-45%
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